|
DACOMITINIB 30 MG TABLET [222939]
|
Facility
OP
|
$622.49
|
|
|
Service Code
|
NDC 0069-1198-30
|
| Hospital Charge Code |
ERX222939
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$149.40 |
| Max. Negotiated Rate |
$529.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$408.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$529.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$342.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$342.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$370.88
|
| Rate for Payer: BCBS Transplant Transplant |
$373.49
|
| Rate for Payer: Blue Shield of California Commercial |
$458.78
|
| Rate for Payer: Blue Shield of California EPN |
$363.53
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cigna of CA HMO |
$435.74
|
| Rate for Payer: Cigna of CA PPO |
$435.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$529.12
|
| Rate for Payer: Dignity Health Media |
$529.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$529.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$249.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$249.00
|
| Rate for Payer: Galaxy Health WC |
$529.12
|
| Rate for Payer: Global Benefits Group Commercial |
$373.49
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$466.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$415.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$237.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$149.40
|
| Rate for Payer: Multiplan Commercial |
$497.99
|
| Rate for Payer: Networks By Design Commercial |
$404.62
|
| Rate for Payer: Prime Health Services Commercial |
$529.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$373.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$373.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$373.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$311.24
|
| Rate for Payer: United Healthcare All Other HMO |
$311.24
|
| Rate for Payer: United Healthcare HMO Rider |
$311.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$311.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$529.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$529.12
|
| Rate for Payer: Vantage Medical Group Senior |
$529.12
|
|
|
DACOMITINIB 45 MG TABLET [222940]
|
Facility
OP
|
$622.49
|
|
|
Service Code
|
NDC 0069-2299-30
|
| Hospital Charge Code |
ERX222940
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$149.40 |
| Max. Negotiated Rate |
$529.12 |
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$408.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$529.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$342.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$342.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$370.88
|
| Rate for Payer: BCBS Transplant Transplant |
$373.49
|
| Rate for Payer: Blue Shield of California Commercial |
$458.78
|
| Rate for Payer: Blue Shield of California EPN |
$363.53
|
| Rate for Payer: Cigna of CA HMO |
$435.74
|
| Rate for Payer: Cigna of CA PPO |
$435.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$529.12
|
| Rate for Payer: Dignity Health Media |
$529.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$529.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$249.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$249.00
|
| Rate for Payer: Galaxy Health WC |
$529.12
|
| Rate for Payer: Global Benefits Group Commercial |
$373.49
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$466.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$415.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$237.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$149.40
|
| Rate for Payer: Multiplan Commercial |
$497.99
|
| Rate for Payer: Networks By Design Commercial |
$404.62
|
| Rate for Payer: Prime Health Services Commercial |
$529.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$373.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$373.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$373.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$311.24
|
| Rate for Payer: United Healthcare All Other HMO |
$311.24
|
| Rate for Payer: United Healthcare HMO Rider |
$311.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$311.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$529.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$529.12
|
| Rate for Payer: Vantage Medical Group Senior |
$529.12
|
|
|
DACOMITINIB 45 MG TABLET [222940]
|
Facility
IP
|
$622.49
|
|
|
Service Code
|
NDC 0069-2299-30
|
| Hospital Charge Code |
ERX222940
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$149.40 |
| Max. Negotiated Rate |
$529.12 |
| Rate for Payer: Blue Shield of California Commercial |
$443.21
|
| Rate for Payer: Blue Shield of California EPN |
$318.71
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cigna of CA HMO |
$435.74
|
| Rate for Payer: Cigna of CA PPO |
$435.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$249.00
|
| Rate for Payer: Galaxy Health WC |
$529.12
|
| Rate for Payer: Global Benefits Group Commercial |
$373.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$415.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$237.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$149.40
|
| Rate for Payer: Multiplan Commercial |
$497.99
|
| Rate for Payer: Networks By Design Commercial |
$404.62
|
| Rate for Payer: Prime Health Services Commercial |
$529.12
|
|
|
DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]
|
Facility
OP
|
$885.00
|
|
|
Service Code
|
CPT J9120
|
| Hospital Charge Code |
1755120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.97 |
| Max. Negotiated Rate |
$1,814.94 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,317.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$836.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$735.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$735.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.97
|
| Rate for Payer: BCBS Transplant Transplant |
$531.00
|
| Rate for Payer: Blue Shield of California Commercial |
$652.24
|
| Rate for Payer: Blue Shield of California EPN |
$1,814.94
|
| Rate for Payer: Cash Price |
$398.25
|
| Rate for Payer: Cash Price |
$398.25
|
| Rate for Payer: Cigna of CA HMO |
$619.50
|
| Rate for Payer: Cigna of CA PPO |
$619.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,003.36
|
| Rate for Payer: Dignity Health Media |
$668.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$735.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$903.02
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$668.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$668.90
|
| Rate for Payer: Galaxy Health WC |
$752.25
|
| Rate for Payer: Global Benefits Group Commercial |
$531.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$663.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,097.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$1,097.00
|
| Rate for Payer: IEHP Medi-Cal |
$1,083.62
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$1,083.62
|
| Rate for Payer: IEHP Medicare Advantage |
$668.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$590.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,279.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$668.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$212.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$842.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$896.33
|
| Rate for Payer: Multiplan Commercial |
$708.00
|
| Rate for Payer: Networks By Design Commercial |
$442.50
|
| Rate for Payer: Prime Health Services Commercial |
$752.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$531.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$531.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$442.50
|
| Rate for Payer: United Healthcare All Other HMO |
$442.50
|
| Rate for Payer: United Healthcare HMO Rider |
$442.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$442.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,003.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$735.79
|
| Rate for Payer: Vantage Medical Group Senior |
$668.90
|
|
|
DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]
|
Facility
IP
|
$885.00
|
|
|
Service Code
|
CPT J9120
|
| Hospital Charge Code |
1755120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$212.40 |
| Max. Negotiated Rate |
$752.25 |
| Rate for Payer: Blue Shield of California Commercial |
$630.12
|
| Rate for Payer: Blue Shield of California EPN |
$453.12
|
| Rate for Payer: Cash Price |
$398.25
|
| Rate for Payer: Cigna of CA HMO |
$619.50
|
| Rate for Payer: Cigna of CA PPO |
$619.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$354.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$354.00
|
| Rate for Payer: Galaxy Health WC |
$752.25
|
| Rate for Payer: Global Benefits Group Commercial |
$531.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$590.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$337.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$212.40
|
| Rate for Payer: Multiplan Commercial |
$708.00
|
| Rate for Payer: Networks By Design Commercial |
$442.50
|
| Rate for Payer: Prime Health Services Commercial |
$752.25
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION [206124]
|
Facility
OP
|
$2,072.77
|
|
|
Service Code
|
CPT J0875
|
| Hospital Charge Code |
ERX206124
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$1,761.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$96.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$16.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$31.77
|
| Rate for Payer: BCBS Transplant Transplant |
$1,243.66
|
| Rate for Payer: Blue Shield of California Commercial |
$1,527.63
|
| Rate for Payer: Blue Shield of California EPN |
$18.97
|
| Rate for Payer: Cash Price |
$932.75
|
| Rate for Payer: Cash Price |
$932.75
|
| Rate for Payer: Cigna of CA HMO |
$1,450.94
|
| Rate for Payer: Cigna of CA PPO |
$1,450.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.94
|
| Rate for Payer: Dignity Health Media |
$15.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.65
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$15.29
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.29
|
| Rate for Payer: Galaxy Health WC |
$1,761.85
|
| Rate for Payer: Global Benefits Group Commercial |
$1,243.66
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,554.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.08
|
| Rate for Payer: Heritage Provider Network Transplant |
$25.08
|
| Rate for Payer: IEHP Medi-Cal |
$24.77
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$24.77
|
| Rate for Payer: IEHP Medicare Advantage |
$15.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,382.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$37.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$497.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.49
|
| Rate for Payer: Multiplan Commercial |
$1,658.22
|
| Rate for Payer: Networks By Design Commercial |
$1,036.38
|
| Rate for Payer: Prime Health Services Commercial |
$1,761.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,243.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,243.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,036.38
|
| Rate for Payer: United Healthcare All Other HMO |
$1,036.38
|
| Rate for Payer: United Healthcare HMO Rider |
$1,036.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,036.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.82
|
| Rate for Payer: Vantage Medical Group Senior |
$15.29
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION [206124]
|
Facility
IP
|
$2,072.77
|
|
|
Service Code
|
CPT J0875
|
| Hospital Charge Code |
ERX206124
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$497.46 |
| Max. Negotiated Rate |
$1,761.85 |
| Rate for Payer: Blue Shield of California Commercial |
$1,475.81
|
| Rate for Payer: Blue Shield of California EPN |
$1,061.26
|
| Rate for Payer: Cash Price |
$932.75
|
| Rate for Payer: Cigna of CA HMO |
$1,450.94
|
| Rate for Payer: Cigna of CA PPO |
$1,450.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$829.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$829.11
|
| Rate for Payer: Galaxy Health WC |
$1,761.85
|
| Rate for Payer: Global Benefits Group Commercial |
$1,243.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,382.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$789.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$497.46
|
| Rate for Payer: Multiplan Commercial |
$1,658.22
|
| Rate for Payer: Networks By Design Commercial |
$1,036.38
|
| Rate for Payer: Prime Health Services Commercial |
$1,761.85
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
OP
|
$8.64
|
|
|
Service Code
|
NDC 0527-1369-06
|
| Hospital Charge Code |
1710002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$7.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.15
|
| Rate for Payer: BCBS Transplant Transplant |
$5.18
|
| Rate for Payer: Blue Shield of California Commercial |
$6.37
|
| Rate for Payer: Blue Shield of California EPN |
$5.05
|
| Rate for Payer: Cash Price |
$3.89
|
| Rate for Payer: Cigna of CA HMO |
$6.05
|
| Rate for Payer: Cigna of CA PPO |
$6.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.34
|
| Rate for Payer: Dignity Health Media |
$7.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.46
|
| Rate for Payer: Galaxy Health WC |
$7.34
|
| Rate for Payer: Global Benefits Group Commercial |
$5.18
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.07
|
| Rate for Payer: Multiplan Commercial |
$6.91
|
| Rate for Payer: Networks By Design Commercial |
$5.62
|
| Rate for Payer: Prime Health Services Commercial |
$7.34
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Other HMO |
$4.32
|
| Rate for Payer: United Healthcare HMO Rider |
$4.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.34
|
| Rate for Payer: Vantage Medical Group Senior |
$7.34
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
IP
|
$8.64
|
|
|
Service Code
|
NDC 0527-1369-06
|
| Hospital Charge Code |
1710002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$7.34 |
| Rate for Payer: Blue Shield of California Commercial |
$6.15
|
| Rate for Payer: Blue Shield of California EPN |
$4.42
|
| Rate for Payer: Cash Price |
$3.89
|
| Rate for Payer: Cigna of CA HMO |
$6.05
|
| Rate for Payer: Cigna of CA PPO |
$6.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: Galaxy Health WC |
$7.34
|
| Rate for Payer: Global Benefits Group Commercial |
$5.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.07
|
| Rate for Payer: Multiplan Commercial |
$6.91
|
| Rate for Payer: Networks By Design Commercial |
$5.62
|
| Rate for Payer: Prime Health Services Commercial |
$7.34
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
OP
|
$7.61
|
|
|
Service Code
|
NDC 0527-1369-01
|
| Hospital Charge Code |
1710002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.53
|
| Rate for Payer: BCBS Transplant Transplant |
$4.57
|
| Rate for Payer: Blue Shield of California Commercial |
$5.61
|
| Rate for Payer: Blue Shield of California EPN |
$4.44
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Cigna of CA HMO |
$5.33
|
| Rate for Payer: Cigna of CA PPO |
$5.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.47
|
| Rate for Payer: Dignity Health Media |
$6.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.04
|
| Rate for Payer: Galaxy Health WC |
$6.47
|
| Rate for Payer: Global Benefits Group Commercial |
$4.57
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$6.09
|
| Rate for Payer: Networks By Design Commercial |
$4.95
|
| Rate for Payer: Prime Health Services Commercial |
$6.47
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.80
|
| Rate for Payer: United Healthcare All Other HMO |
$3.80
|
| Rate for Payer: United Healthcare HMO Rider |
$3.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.47
|
| Rate for Payer: Vantage Medical Group Senior |
$6.47
|
|
|
DANAZOL 200 MG CAPSULE [2120]
|
Facility
IP
|
$7.61
|
|
|
Service Code
|
NDC 0527-1369-01
|
| Hospital Charge Code |
1710002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Blue Shield of California Commercial |
$5.42
|
| Rate for Payer: Blue Shield of California EPN |
$3.90
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Cigna of CA HMO |
$5.33
|
| Rate for Payer: Cigna of CA PPO |
$5.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.04
|
| Rate for Payer: Galaxy Health WC |
$6.47
|
| Rate for Payer: Global Benefits Group Commercial |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$6.09
|
| Rate for Payer: Networks By Design Commercial |
$4.95
|
| Rate for Payer: Prime Health Services Commercial |
$6.47
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
IP
|
$1.97
|
|
|
Service Code
|
NDC 0115-4433-01
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Blue Shield of California Commercial |
$1.40
|
| Rate for Payer: Blue Shield of California EPN |
$1.01
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO |
$1.38
|
| Rate for Payer: Cigna of CA PPO |
$1.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Galaxy Health WC |
$1.67
|
| Rate for Payer: Global Benefits Group Commercial |
$1.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: Networks By Design Commercial |
$1.28
|
| Rate for Payer: Prime Health Services Commercial |
$1.67
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
OP
|
$1.57
|
|
|
Service Code
|
NDC 0527-3221-37
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: BCBS Transplant Transplant |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO |
$1.10
|
| Rate for Payer: Cigna of CA PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Media |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Networks By Design Commercial |
$1.02
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.94
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.79
|
| Rate for Payer: United Healthcare All Other HMO |
$0.79
|
| Rate for Payer: United Healthcare HMO Rider |
$0.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
IP
|
$1.57
|
|
|
Service Code
|
NDC 0527-3221-37
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO |
$1.10
|
| Rate for Payer: Cigna of CA PPO |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Networks By Design Commercial |
$1.02
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
|
|
DANTROLENE 100 MG CAPSULE [9717]
|
Facility
OP
|
$1.97
|
|
|
Service Code
|
NDC 0115-4433-01
|
| Hospital Charge Code |
1710047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.17
|
| Rate for Payer: BCBS Transplant Transplant |
$1.18
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.15
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO |
$1.38
|
| Rate for Payer: Cigna of CA PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.67
|
| Rate for Payer: Dignity Health Media |
$1.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.79
|
| Rate for Payer: Galaxy Health WC |
$1.67
|
| Rate for Payer: Global Benefits Group Commercial |
$1.18
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: Networks By Design Commercial |
$1.28
|
| Rate for Payer: Prime Health Services Commercial |
$1.67
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.99
|
| Rate for Payer: United Healthcare All Other HMO |
$0.99
|
| Rate for Payer: United Healthcare HMO Rider |
$0.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Vantage Medical Group Senior |
$1.67
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
IP
|
$84.00
|
|
|
Service Code
|
NDC 78670-003-67
|
| Hospital Charge Code |
1720074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.16 |
| Max. Negotiated Rate |
$71.40 |
| Rate for Payer: Blue Shield of California Commercial |
$59.81
|
| Rate for Payer: Blue Shield of California EPN |
$43.01
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.16
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: Networks By Design Commercial |
$54.60
|
| Rate for Payer: Prime Health Services Commercial |
$71.40
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [9716]
|
Facility
OP
|
$84.00
|
|
|
Service Code
|
NDC 78670-003-67
|
| Hospital Charge Code |
1720074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.16 |
| Max. Negotiated Rate |
$71.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$55.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$46.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$46.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$50.05
|
| Rate for Payer: BCBS Transplant Transplant |
$50.40
|
| Rate for Payer: Blue Shield of California Commercial |
$61.91
|
| Rate for Payer: Blue Shield of California EPN |
$49.06
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna of CA HMO |
$53.76
|
| Rate for Payer: Cigna of CA PPO |
$62.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.40
|
| Rate for Payer: Dignity Health Media |
$71.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$33.60
|
| Rate for Payer: Galaxy Health WC |
$71.40
|
| Rate for Payer: Global Benefits Group Commercial |
$50.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$63.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.16
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: Networks By Design Commercial |
$54.60
|
| Rate for Payer: Prime Health Services Commercial |
$71.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$50.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$50.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.00
|
| Rate for Payer: United Healthcare All Other HMO |
$42.00
|
| Rate for Payer: United Healthcare HMO Rider |
$42.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$42.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$71.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.40
|
| Rate for Payer: Vantage Medical Group Senior |
$71.40
|
|
|
DANTROLENE 250 MG INTRAVENOUS SUSPENSION [206686]
|
Facility
OP
|
$3,752.10
|
|
|
Service Code
|
NDC 42367-540-32
|
| Hospital Charge Code |
ERX206686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$900.50 |
| Max. Negotiated Rate |
$3,189.28 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,461.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,189.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,063.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,063.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,235.50
|
| Rate for Payer: BCBS Transplant Transplant |
$2,251.26
|
| Rate for Payer: Blue Shield of California Commercial |
$2,765.30
|
| Rate for Payer: Blue Shield of California EPN |
$2,191.23
|
| Rate for Payer: Cash Price |
$1,688.45
|
| Rate for Payer: Cash Price |
$1,688.45
|
| Rate for Payer: Cigna of CA HMO |
$2,626.47
|
| Rate for Payer: Cigna of CA PPO |
$2,626.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,189.28
|
| Rate for Payer: Dignity Health Media |
$3,189.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,189.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,500.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,500.84
|
| Rate for Payer: Galaxy Health WC |
$3,189.28
|
| Rate for Payer: Global Benefits Group Commercial |
$2,251.26
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2,814.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,502.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,429.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$900.50
|
| Rate for Payer: Multiplan Commercial |
$3,001.68
|
| Rate for Payer: Networks By Design Commercial |
$1,876.05
|
| Rate for Payer: Prime Health Services Commercial |
$3,189.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,251.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,251.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,876.05
|
| Rate for Payer: United Healthcare All Other HMO |
$1,876.05
|
| Rate for Payer: United Healthcare HMO Rider |
$1,876.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,876.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,189.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,189.28
|
| Rate for Payer: Vantage Medical Group Senior |
$3,189.28
|
|
|
DANTROLENE 250 MG INTRAVENOUS SUSPENSION [206686]
|
Facility
IP
|
$3,752.10
|
|
|
Service Code
|
NDC 42367-540-32
|
| Hospital Charge Code |
ERX206686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$900.50 |
| Max. Negotiated Rate |
$3,189.28 |
| Rate for Payer: Blue Shield of California Commercial |
$2,671.50
|
| Rate for Payer: Blue Shield of California EPN |
$1,921.08
|
| Rate for Payer: Cash Price |
$1,688.45
|
| Rate for Payer: Cigna of CA HMO |
$2,626.47
|
| Rate for Payer: Cigna of CA PPO |
$2,626.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,500.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,500.84
|
| Rate for Payer: Galaxy Health WC |
$3,189.28
|
| Rate for Payer: Global Benefits Group Commercial |
$2,251.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,502.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,429.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$900.50
|
| Rate for Payer: Multiplan Commercial |
$3,001.68
|
| Rate for Payer: Networks By Design Commercial |
$1,876.05
|
| Rate for Payer: Prime Health Services Commercial |
$3,189.28
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
OP
|
$0.97
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.58
|
| Rate for Payer: BCBS Transplant Transplant |
$0.58
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.57
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO |
$0.68
|
| Rate for Payer: Cigna of CA PPO |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Media |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO |
$0.49
|
| Rate for Payer: United Healthcare HMO Rider |
$0.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
OP
|
$1.95
|
|
|
Service Code
|
NDC 68084-300-21
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.16
|
| Rate for Payer: BCBS Transplant Transplant |
$1.17
|
| Rate for Payer: Blue Shield of California Commercial |
$1.44
|
| Rate for Payer: Blue Shield of California EPN |
$1.14
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO |
$1.36
|
| Rate for Payer: Cigna of CA PPO |
$1.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.66
|
| Rate for Payer: Dignity Health Media |
$1.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.78
|
| Rate for Payer: Galaxy Health WC |
$1.66
|
| Rate for Payer: Global Benefits Group Commercial |
$1.17
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.56
|
| Rate for Payer: Networks By Design Commercial |
$1.27
|
| Rate for Payer: Prime Health Services Commercial |
$1.66
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.98
|
| Rate for Payer: United Healthcare All Other HMO |
$0.98
|
| Rate for Payer: United Healthcare HMO Rider |
$0.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.66
|
| Rate for Payer: Vantage Medical Group Senior |
$1.66
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
IP
|
$0.78
|
|
|
Service Code
|
NDC 0527-3219-37
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.51
|
| Rate for Payer: Prime Health Services Commercial |
$0.66
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
IP
|
$0.97
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Blue Shield of California Commercial |
$0.69
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO |
$0.68
|
| Rate for Payer: Cigna of CA PPO |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
IP
|
$1.95
|
|
|
Service Code
|
NDC 68084-300-21
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO |
$1.36
|
| Rate for Payer: Cigna of CA PPO |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Galaxy Health WC |
$1.66
|
| Rate for Payer: Global Benefits Group Commercial |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.56
|
| Rate for Payer: Networks By Design Commercial |
$1.27
|
| Rate for Payer: Prime Health Services Commercial |
$1.66
|
|
|
DANTROLENE 25 MG CAPSULE [9718]
|
Facility
OP
|
$0.78
|
|
|
Service Code
|
NDC 0527-3219-37
|
| Hospital Charge Code |
1710016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.46
|
| Rate for Payer: BCBS Transplant Transplant |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.66
|
| Rate for Payer: Dignity Health Media |
$0.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.51
|
| Rate for Payer: Prime Health Services Commercial |
$0.66
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.39
|
| Rate for Payer: United Healthcare All Other HMO |
$0.39
|
| Rate for Payer: United Healthcare HMO Rider |
$0.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Vantage Medical Group Senior |
$0.66
|
|
